Local Glucocorticoid Injections in Soft Tissues and Joints

Principles

• The skin is carefully cleaned with spirit-containing cleanser, and good aseptic principles are followed in performing the puncture. The site of the injection is determined and marked before cleansing (video Marking the Site for Puncture).
• If an ultrasound device is available, it is used, as necessary, to check the existence and location of fluid.
• Soft tissues, the glenohumeral joint, the subacromial bursa and the trochanteric bursa are treated with an injection containing a glucocorticoid and a local anaesthetic in the proportion of 1:1 to 1:2, or a glucocorticoid and 0.9% NaCl in the proportion of 1:1. Small joints, other joints (provided that fluid can be obtained through aspiration) and bursae are treated with glucocorticoid only without an anaesthetic. An observed local effect of the anaesthetic soon after the injection also serves as a diagnostic test in the treatment of disorders in the glenohumeral region and in bursitides.
• Intra-articular injections should be reserved for inflamed joints: swelling or hydrops and pain (see Clinical Diagnosis of Joint Inflammation in the Adult).
• Triamcinolone
  • In the knee joint 20-40 mg
  • In other large joints (elbow, wrist) 20 mg if there is obvious inflammation or if fluid can be aspirated
• Methylprednisolone12-80 mg depending on the size of joint/injection area
  • In smaller joints and soft tissues. Because of the risk of skin atrophy (picture 1), intracutaneous or subcutaneous injection should be avoided.
  • In the finger tendon sheaths
• The needle should be as thin (see table T1) and the pressure applied as light as possible (do not inject against a counter pressure) so as not to damage the joint cartilage or tendons.
• Aspiration of the joint before a glucocorticoid is injected enhances the therapeutic effect at least in rheumatoid arthritis.
• In acute arthritis, injection to the same large joint more frequently than once a month during the first 3 months or more than 4 injections per year is not recommended. Smaller joints (other than weight-bearing joints) may be injected more frequently. In osteoarthritis, the same joint should not be injected more frequently than at 3-month intervals, and injections should only be given if other treatments are insufficient. There is no unambiguous evidence on the possible harm to the joint cartilage caused by repeated injections. Systemic adverse effects are possible if injections are given more frequently than at 4-6-week intervals.
• Partial immobilization of the joint for 24 hours and avoiding vigorous exercise for a week after the injection improves the result of the treatment, at least as far as the large joints are concerned.
  • In weight-bearing joints, the immobilization should be as complete as possible for 24 hours. Without immobilization, the drug is absorbed too quickly from the joint to the blood circulation and its effect is decreased.

Injection sites

Recommended quantity of injection fluid

• A ready-made combination of a glucocorticoid and a local anaesthetic is used, or the glucocorticoid is diluted with a local anaesthetic or with saline, if needed.
• The knee joint: 1 ml of glucocorticoid
  • The same amount is used in Baker's cyst. The injection is given into the knee joint if there is effusion in the joint; otherwise, the injection can be given directly into the cyst.
• The glenohumeral joint: 1 ml of glucocorticoid and 1-2 ml of local anaesthetic (video Restricted Motion of the Shoulder; Intra-Articular Injection); the subacromial bursa: 1 ml of glucocorticoid and 1(-2) ml of local anaesthetic
• The ankle joint: 1 ml
• The wrist joint: 0.5 ml (video Restricted Motion of the Wrist in a Patient with Rheumatoid Arthritis)
• Soft tissues: 0.4-1 ml and the same quantity of local anaesthetic or 0.9% NaCl (video Flexor Tenosynovitis in Rheumatoid Arthritis)
• PIP-joints: 0.15 ml of glucocorticoid (0.15 ml of anaesthetic may additionally be administered)
• MCP and MTP joints, temporomandibular joints: 0.2 ml of glucocorticoid (0.2 ml of anaesthetic may additionally be administered)

Recommended needle size

• See table T1.
• When a large needle is used for the injection it is recommended first to apply local anaesthesia to the injection site using as small a needle as possible.

Other injection therapies

• Intra-articular hyaluronate injections may to some degree relieve the symptoms in osteoarthritis of the knee Intra-Articular Hyaluronic Acid for Knee Osteoarthritis , but the benefit-risk ratio is uncertain. Hyaluronate may be tried for the treatment of knee osteoarthritis if glucocorticoid injections are not effective.